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The contribution of eHealth and mHealth to improving the performance of the health workforce: a review

Authors:

Abstract

Introduction: eHealth and mHealth are technologies that allow services to be extended closer to patients, in pursuit of the objectives of Health 2020: a European policy framework and strategy for the 21st century and of the Global Strategy on Human Resources for Health: workforce 2030. As Europe faces increased demand for health services due to ageing populations, rising patient mobility, and a diminishing supply of health workers caused by retirement rates that surpass recruitment rates, this paper illustrates how eHealth and mHealth can improve the delivery of services by the health workforce in response to increasing demands. Methods: Through a scoping literature review, the impact of eHealth/mHealth on the health workforce was assessed by examining how these technologies affect four dimensions of the performance of health professionals, according to the so-called AAAQ: availability, accessibility, acceptability, and quality. Results: Few high-quality studies were found. Most studies focused on the utilization of text messaging (SMS) for patient behavior change, and some examined the potential of mhealth to strengthen health systems. We also found some limited literature reporting effects on clinical effectiveness, costs, and patient acceptability; we found none reporting on equity and safety issues. Facilitators and barriers to the optimal utilization of eHealth and mHealth were identified and categorized as they relate to individuals, professional groups, provider organizations, and the institutional environment. Discussion: There are ongoing clinical trial protocols of largescale, multidimensional mHealth interventions, suggesting that the current limited evidence base will expand in coming years. The requirement for new digital skills for human resources for health (HRH) was observed as significant. This has implications for the education of health workers, the management of health services, policy-making, and research.
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INTRODUCTION
e potential contribution of eHealth and mHealth to making health care delivery more eective is broadly
recognized (1). Here we refer to eHealth as the “cost-eective and secure use of information and communication
technologies in support of health and health-related elds, including health care services, health surveillance,
health literature, and health education"; and to mHealth as the “use of mobile and wireless technologies to sup-
port the achievement of health objectives” (1, 41).
In Europe, their use is already extensive in some countries, while their use in the majority has just begun. Among
other requirements, the implementation of eHealth/mHealth-based services depends on the availability of health
professionals, administrative and support sta, and managers with adequate new digital skills (2). Innovations
such as the provision of alerts to patients for therapeutic guidance and for monitoring drug adherence, or digital
support to clinical and administrative tasks, oer the potential of making services more accessible, eective and
POLICY AND PRACTICE
The contribution of eHealth and mHealth to improving the
performance of the health workforce: areview
Luís Velez Lapão1, Gilles Dussault1
1Global H ealth and Tropica l Medicine, Instituto de Higi ene eMedicina Tropical, Universidade Nova de Lisboa, Li sbon, Portu gal
Corresponding author: Luís Velez Lapão (email: luis.lapao@ihmt.unl.pt)
ABSTRACT
Introduction:
eHealth and mHealth are technologies that allow
services to be extended closer to patients, in pursuit of the
objectives of Health 2020: a European policy framework and
strategy for the 21st century and of the Global Strategy on Human
Resources for Health: workforce2030. As Europe faces increased
demand for health services due to ageing populations, rising
patient mobility, and a diminishing supply of health workers
caused by retirement rates that surpass recruitment rates,
this paper illustrates how eHealth and mHealth can improve
the delivery of services by the health workforce in response to
increasing demands.
Methods:
Through a scoping literature review, the impact of
eHealth/mHealth on the health workforce was assessed by
examining how these technologies affect four dimensions of the
performance of health professionals, according to the so-called
AAAQ: availability, accessibility, acceptability, and quality.
Results:
Few high-quality studies were found. Most studies
focused on the utilization of text messaging (SMS) for patient
behavior change, and some examined the potential of mhealth
to strengthen health systems. We also found some limited
literature reporting effects on clinical effectiveness, costs, and
patient acceptability; we found none reporting on equity and
safety issues. Facilitators and barriers to the optimal utilization
of eHealth and mHealth were identied and categorized as they
relate to individuals, professional groups, provider organizations,
and the institutional environment.
Discussion:
There are ongoing clinical trial protocols of large-
scale, multidimensional mHealth interventions, suggesting that
the current limited evidence base will expand in coming years.
The requirement for new digital skills for human resources for
health (HRH) was observed as signicant. This has implications
for the education of health workers, the management of health
services, policy-making, and research.
Keywords: EHEALTH/MHEALTH; HUMAN RESOURCES FOR HEALTH; HEALTH WORKFORCE PERFORMANCE;
DIGITALIZATION OF HEALTH
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THE CONTRIBUTION OF EHEALTH AND MHEALTH TO IMPROVING THE PERFORMANCE OF THE HEALTH
WORKFORCE: AREVIEW
ecient. Such services are expected to benet the users of services, health care professionals, provider organiza-
tions and the entire health care system, in the form of increased safety, quality of services, and eciency gains (3).
However, many obstacles to the implementation of eHealth/mHealth remain (4).
is paper focusses on addressing how eHealth/mHealth can increase the availability, accessibility, acceptability
and quality (AAAQ) of the health workforce (2), and thereby scale-up its capacity to deliver services that are bet-
ter aligned with population needs.
We present examples that illustrate how eHealth and mHealth are used and how they improve performance and
thereby “help improve the lives of European citizens, both patients and health professionals, while tackling the
challenges to health care systems” (5). We also include examples of countries with advanced implementation, and
discuss facilitators and barriers to the optimal utilization of new communication and management technologies
and their implications for the education of health workers, service management, policy-making, and research.
But rst, the general picture of their utilization in Europe is reviewed.
METHODS
A scoping review of literature published in English was performed on the utilization of eHealth/mHealth in Eu-
rope; the search in the PubMed and Google Scholar databases combined the following terms: Human Resources
for Health, eHealth, mHealth, healthcare service delivery, and digital skills.
e example of two so-called digitally advanced countries, identied as such by the European momentum for
mainstreaming telemedicine deployment in daily practice (MOMENTUM), aplatform where clinicians share their
experience in deploying telemedicine services into routine care (6), was used. ese are Norway, as this country’s
geography led to the necessity of deploying ehealth to address health coverage issues; and Portugal, a small
country with anational centralized ehealth system. e examples were documented in detail to draw lessons on
what enables or impedes the optimal utilization of ehealth/mhealth technologies, and on changes observed in the
performance of the health workforce. e literature review and the country examples were analyzed according to
the AAAQ dimensions. is in turn helped identify the impact of ehealth/mhealth on the education and manage-
ment of health workers and on related policy and research.
RESULTS
e literature review identied several examples of using eHealth and mHealth technologies in the process of
the digitalization of health care services, including support for electronic health records, electronic prescription
and Internet-of-ings (equipping patients’ home with sensors to monitor and transfer health data), and big data/
articial intelligence (7).
Most studies focused narrowly on text messaging systems for patient behavior change, and afew studies examined
systems for strengthening aspects of eHealth/mHealth (8). ere was limited literature on clinical eectiveness,
costs, and patient acceptability, and none on equity and safety issues. In addition, there were only four papers
on eHealth/mHealth and digital skills requirements for health professionals (9–12). Despite the bold promise of
eHealth/mHealth to improve health care, much remains unknown about whether and how this will be fullled.
We identied registered clinical trial protocols of large-scale, multidimensional eHealth/mHealth interventions,
suggesting that the current limited evidence base will expand in the coming years.
e results are presented in three par ts: eHealth/mHealth in Europe, case studies of Norway and Portugal, and the
impact on the performance of the health workforce and conditions for successful implementation and utilization.
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THE CONTRIBUTION OF EHEALTH AND MHEALTH TO IMPROVING THE PERFORMANCE OF THE HEALTH
WORKFORCE: AREVIEW
EHEALTH AND MHEALTH IN THE EUROPEAN REGION
e literature suggests that eHealth/mHealth can be used as tools to meet the challenges of healthy ageing and
universal and equitable access to health services in the context of the increasing burden of chronic diseases (13).
More specically, eHealth/mHealth has showed capacity to:
improve access to awide range of services at all levels of health care– primary, secondary and tertiary– cover-
ing conditions such as mental illness, heart and cerebrovascular disease, diabetes, cancer and trauma. Services
such as radiology, pathology and rehabilitation have also beneted (14 , 15);
promote individualized, patient-centered care at alower cost (16, 17) ;
enhance eciency in clinical decision-making and prescribing, through easier communication between health
care providers (14);
increase the eectiveness of chronic disease management in both long-term care facilities and at home (14);
promote the adoption of healthy lifestyles and self-care (18).
As of 2008, the European Commission adopted a policy to encourage the development of telemedicine (5). It
identied the ways in which telemedicine services might assist patients, particularly those living in remote areas
or experiencing conditions that might not be treated as easily or as oen as needed. It also cited specic benets,
such as: improving access to health care by giving access to specialists who are not available locally, and; at the
organizational level, helping to shorten patient waiting lists, to optimize the use of resources and enable produc-
tivity gains.
In the last decade, anumber of European, national and regional initiatives have been launched in support of
the development of eHealth/mHealth under the Competitiveness and Innovation Programme– in particular its
Policy Support Programme (19), and its pilot experiments or European FP7 projects such as Renewing Health (20),
United4Health (21), and Digital Agenda for Europe (22). Major policy documents, such as Horizon 2020 (23), the
European Innovation Partnership (EIP) and its rst partnership on Active and Healthy Ageing (AHA) (24), the
2012 European eHealth Action Plan (5), and the New Health Technologies: Managing Access, Value and Sustain-
ability (25), have highlighted the value of using technologies, such as eHealth/mHealth, in health care. e 2008
European Health Telematics Association (EHTEL) brief, Sustainable Telemedicine: paradigms for future-proof
healthcare, proposed good practices in the use of ICT in integrated care (6). e deployment of eHealth/mHealth
is already the objective of several European initiatives (see Box 1).
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BOX 1: EHEALTH/MHEALTH INITIATIVES AND ACTIONS IN THE EUROPEAN REGION
European Momentum for Mainstreaming Telemedicine Deployment in Daily Practice (http://www.telemedicine-
momentum.eu/) (2012–15)
European Innovation Partnership on Active and Healthy Ageing (https://ec.europa.eu/eip/ageing/home_en) (2014–20)
Discussion Paper: Filling the Gap: Legal and Regulatory Challenges of Mobile Health (mHealth) in Europe (ITU, 2014)
EU Green Paper (2014) on the potential of mHealth for health care services
EU project DECIPHER PCP, to create amobile health care platform which would enable secure cross-border access to
existing patient health care portals. (www.decipherpcp.eu) (2013–17)
Renewing Health: aimed at implementing large‐scale, real-life testbeds for the validation and subsequent evaluation
of innovative eHealth/mHealth services for the remote monitoring and treatment of chronic patients suffering from
diabetes, chronic obstructive pulmonary disease or cardiovascular diseases. Nine regions from different European
countries participate: Regione Veneto (Italy), Region Syddanmark (Denmark– Coordinator), Northern Norway Regional
Health Authority (Norway), South Karelia Social and Health Care District (Finland), County Council of Norrbotten
(Sweden), Catalunya (Spain), Region of Central Greece, Carinthia (Austria), and Land of Berlin (Germany). (2011–14)
Centre for Telemedicine and Telehealthcare, 2012, Central Denmark Region (http://www.smartaarhus.eu/projects/
centre-telemedicine-and-telehealthcare).
An implementation resource that focuses on coaching, monitoring and consultations for people with long-term
conditions, developed by the University of York to address innovation in long-term care (26).
A toolkit that provides astructured approach to delivering the business objectives of eHealth/mHealth, developed to
support the UK’s National Health Service challenge to leverage the use of mHealth (27).
A collection of eHealth/mHealth case studies (http://www.cocir.org/leadmin/ Publications_2011/telemedicine_
toolkit_link2.pdf)(28).
A collection of eHealth/mHealth testimonials collected by the campaign for eHealth/mHealth in support of integrated
care, a2011 initiative of Brussels-based organizations (http://telemedicine-momentum.eu/testimonials/) (29, 32).
Currently, eHealth/mHealth exists through three main types of services: diagnosis, monitoring and consultation:
Diagnosis: The results of x-ray, ultrasound, CT, MRI, ECG or Holter exams are sent digitally from adiagnostic device
to the appropriate health professionals who in turn make adiagnosis that is sent digitally to the referring physician or
diagnostic clinic.
Monitoring: Data derived from eHealth/mHealth devices measuring patient vital signs are tracked by a monitoring
centre, individual clinician or website. Typically, the recipient of the data uses clinical guidelines to identify any deviation
from what is considered normal for that patient. Embedded algorithms, written guidelines or professional judgment all
support this process. If an unusual event occurs, the monitoring process generates aresponse in the form of an alert,
contact with aclinician, or some form of online guidance to the patient.
Consultation: When avirtual visit or dialogue takes place instead of, or in addition to, aface-to-face encounter.
TWO EXAMPLES OF UTILIZATION OF EHEALTH/MHEALTH IN NORWAY
ANDPORTUGAL
NORWAY
e Electronic platform for integrated home care of long lasting and chronic ulcers at the University of North Nor-
way Hospital (UNN: http://www.telemedicine-momentum.eu/ulcers-no/) aims to facilitate cooperation between
the patient, out-patient clinic at the hospital, patient’s general practitioner, and home care personnel. e platform
is aweb-based electronic health record available via the Internet that can be used from computers, mobile phones
and tablets. It is possible to register digital images of ulcers, compare images over time, ask for advice, and discuss
the most appropriate treatment. is service is expected to lead to better care, better quality of life for the patient,
and more eective treatment. It is expected that the number of hospital visits will be reduced along with resulting
cost-savings. It also leads to the upgrading of ulcer treatment skills among involved home care personnel.
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e service covers patients with chronic conditions and those undergoing aspecic treatment. Up to ten people
receive the service each month. is service oers diagnosis, mobile access to information, monitoring, therapy
and treatment. Local health personnel as well as the patient can send images and questions electronically to the
hospital, receive answers, and discuss dierent options for action.
PORTUGAL
For every 1000 newborns worldwide, eight contract some type of cardiopathy (29, 30). For children delivered in
District Hospitals, telemedicine allows for arapid and valid diagnosis of complex paediatric cardiopathies and
for an adapted follow-up.
e Hospital Pediátrico de Coimbra (HPC) is a95-bed hospital that serves central Portugal and apopulation of
2.3 million representing about 25% of the total population of the country. In October 1998, HPC launched Medi-
graf, an eHealth system for teleconsultation that enables the reading of an eco-cardiogram in real-time at adis-
tance, for example, in district hospitals (29). It is also possible to communicate by telephone with aphysician
usually apaediatrician– based at HPC, in order to make acomplete distance examination. Images and sounds
can be recorded in the system database and made available at both ends. In practice, the project experienced some
barriers, such as in communicating the objectives of the telemedicine service, being seen as anon-user-friendly
technology, not being clear regarding the remuneration of consultations, and insucient training. Leaders of the
project promoted the participation of physicians in apilot experiment and invited other regional hospitals to join
the task force responsible for the development of the experiment at HPC. Workshops to train physicians in the use
of telemedicine were conducted and helped raise their interest in the project.
IMPACT OF EHEALTH/MHEALTH ON THE PERFORMANCE OF THE HEALTH
WORKFORCE
Literature remains scarce about how these new services aect the health workforce: here we examine what the
literature says about the AAAQ dimensions of the health workforce:
Availability: e more general literature indicates that the utilization of eHealth/mHealth augments
the productivity of clinicians thanks to time-saving practices, less paper work and more rapid access to
information. Higher productivity translates into increased availability and capacity to provide services to
more users, even if the absolute numbers of health professionals remain constant (8, 9, 28, 29, 31, 33, 34).
Accessibility: Accessibility improves as providers intervene at a distance, with the capacity to diagnose
problems and monitor patient conditions through mobile devices (14, 3 0 , 31). Specialists, who typically
concentrate in urban areas and higher-complexity clinics and hospitals, become accessible as they interact
with their colleagues in general practice or directly with patients, irrespective of distance. is has the
potential to facilitate the development of home care as well as the integration of services (10, 12, 18, 29, 35).
Acceptability: eHealth/mHealth services make communication with patients easier, and more direct and
adapted to each individual needs, thereby potentially enhancing the acceptability of providers. is is more
likely with younger persons who are more familiar with the utilization of computers and mobile devices;
strategies to facilitate their use by older patients may therefore be needed (14, 28, 36).
Quality: Finally, eHealth and mHealth tools give providers rapid access to valid information, second opinions
and guidelines, all of which contribute to scaling-up the competencies and compliance with professional
standards, and thereby improving patient safety and service eectiveness (7, 10, 18, 28, 30).
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DISCUSSION
Online services are already changing how many sectors of the economy function, but they are relatively new in
health care. is raises questions about what can facilitate their utilization, and which barriers need to be over-
come to make real the potential performance gains of health workers and health services. eHealth/mHealth is
not apanacea, but it oers signicant opportunities to improve access to care, contain costs and scale-up quality.
Facilitators and barriers have been identied in relation to: individuals, such as patients, providers and managers;
professional associations; provider organizations; and the institutional and regulatory environment. e acquisi-
tion or development of digital skills by health workers is critical. is has implications for the education of health
workers, the management of health services, policy-making and research. Proper eHealth service implementation
requires adjustments in service delivery and in how work is organized (37–38).
Competencies to work in adigitalized environment have already been identied as among the core competencies
which health professionals must have to deliver the services that meet the current and future needs of populations
(39, 4 0). e policy challenge here is for educational institutions to adapt the contents of curricula and learning
strategies to prepare future professionals for transformed ways of practicing; it also includes the need to help the
existing workforce acquire digital skills which did not exist when they were initially educated. Curricular changes
are notoriously long to make as they imply the review of accreditation norms, retraining of teaching sta or the
introduction of new mechanisms to evaluate competencies.
e impact of eHealth/mHealth on the provision of services will aect the availability of the health workforce
dierently, depending on the type of service. In some instances, it may lead to areduction of needs if productivity
increases and demand remains constant. More likely, it will generate additional and new needs. For instance, as
these tools enable reaching out to populations previously without access to some categories of health workers
such as medical specialists, physiotherapists and psychologists– the demand for the services of these profession-
als will increase. Also, as professionals are now able to monitor patients remotely, more physicians, nurses and
pharmacists will be needed to respond to ademand in rapid growth from apopulation of patients with one, and
oen more than one, chronic condition. New categories of professionals in telenursing, telepharmacy, health data
analysis, and most probably in other areas and functions which are not yet known, will also be needed.
e facilitators and barriers to the diusion of eHealth/mHealth are not very dierent from that of other inno-
vations. eir adoption as routine tools by health workers and provider organizations will be facilitated by the
favorable cost-benet ratio of their utilization. As costs continuously drop, the power and potential of these tools
will rise. Also, the new generations of health workers born into arapidly digitalized environment are less likely
to resist adopting these tools; on the contrary, it can even be expected that they will contribute to their further
development. Factors such as engaging stakeholders in implementing change, the visibility of its advantages and
user-friendliness, the leadership of respected so-called champions, access to training, the commitment and sup-
port of managers and decision-makers, good planning, and an enabling nancial and legal environment can all
play apositive role (41). eir absence can constitute barriers, but in the case of eHealth/mHealth, the risks of
barriers being stronger than facilitators are reduced. For instance, atypical barrier such as the resistance of older
workers becomes less of an issue as the new tools become more user-friendly and as their utility for the worker,
patient and organization is almost immediately apparent.
e technology is changing more rapidly than the organizational and institutional environment. Issues linked
to legal responsibility, the denition of scopes of practice, remuneration and reimbursement, and the standard-
ization of tools are starting to be addressed (6, 32, 42). ese are particularly dicult in acontext such as that
of the European Union where the mobility of health workers and patients is afundamental right. Another issue
relates to planning the future health workforce in acontext of rapid technological, demographic, epidemiological,
economic and social change.
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ere are two principal limitations to this article. First, it only covers publications in English. It does not include
publications in French, Portuguese, Russian or Spanish that report experiences of the utilization of eHealth/
mHealth in countries where these languages are used, although researchers tend to publish in English to reach
out to a broader audience. e second, more important, limitation is that the literature reviewed does not include
studies that report experiences evaluated according to a rigorous research protocol. Information on the results
of experiences is based primarily on administrative evaluations and on assessments by providers and patients.
CONCLUSION
It is aparadox that the uptake of eHealth/mHealth services is more advanced in some low-income countries than
in more economically developed one. is is changing rapidly as numerous initiatives to promote and facilitate
their use have been launched and as some countries are becoming good models of integration for new commu-
nication technologies. e challenge remains to move from the recognition of the potential benets of eHealth/
mHealth to their actual utilization on alarge scale, in aroutine manner. In the European context, there seems to
be more facilitators than barriers which bodes well for the future of health services in terms of improved accessi-
bility, eectiveness and eciency. It also oers the potential for better working conditions and higher satisfaction
for health workers as they will be better equipped to do their job.
e benets of eHealth/mHealth will not come spontaneously. An enabling policy environment is aprerequisite,
as is the case for any major change. Research can help inform the policy process if it is well targeted and if its re-
sults are communicated to policy-makers in away that encourages and supports their utilization. Policy-makers
will be interested in the economics of the utilization of eHealth/mHealth; direct costs may be low and there may
be savings from less visits and hospitalizations, but indirect costs also need to be assessed, whether it is for train-
ing or through increased demand induced by the greater accessibility facilitated by the technologies. Research
on the process of implementation of eHealth/mHealth-based services is also important, including cross-national
comparisons and studies. Another topic for research, more complex to study but most relevant, is their impact on
health outcomes.
Acknowledgements: None declared.
Sources of fund ing: is work was supported in part by the Portuguese Fundação pa ra aCiência ea Tecnologia
(FCT) funds (UID/Multi/04413/2013).
Conicts of interest: None declared.
Disclaimer: e authors alone are responsible for the views expressed in this publication and they do not
necessarily represent the decisions or policies of the World Health Organization.
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THE CONTRIBUTION OF EHEALTH AND MHEALTH TO IMPROVING THE PERFORMANCE OF THE HEALTH
WORKFORCE: AREVIEW
... To build up a shared ecosystem of health information, the Portuguese Ministry of Health created an Electronic Health Record (EHR) called "Sclínico," which is unfortunately not yet available in all health units of the Portuguese National Health Service (NHS) [40]. More recently, another digital service was made available on the NHS' digital platform to allow the sharing of clinical information between all levels of health care and to These healthcare solutions have revealed the potential to provide quality health services with complete, interoperable data in near real-time [17][18][19][20], and eHealth services with the engagement of patients and families for self and remote management of chronic conditions and prevention of risky behaviors [2,[20][21][22]. Indeed, many researchers have studied the potential of digital sensors to identify early balance deficit and identify fallers among elderly people, improving the data quality of clinical tests and functional scales as the Timed Up and Go Test (TUGT) and the Berg Balance Scale [23][24][25][26][27][28][29]. ...
... These limitations and consequent costs have been reported by other authors [4,[12][13][14][15]. The participants pointed out the need for investments in the interoperability of health information systems and in the organization of work to overcome this situation, as previously proposed in other studies [19][20][21]. In fact, data are essential for healthcare provision, monitoring of population health status and decision making. ...
... Only one interviewed revealed skepticism about digital solutions due to the lack of eHealth clinical experience. Several studies have already revealed the influence of limited knowledge about telemedicine on the perception of the potential of eHealth [19,35]. ...
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This study aimed to identify relevant topics for the development of an efficient eHealth service for elderly people with balance disorders and risk of falling, based on input from physicians providing healthcare to this patient group. In the quantitative part of the study, an open multiple-choice questionnaire was made available on the website of the Portuguese General Medical Council to assess the satisfaction with electronic medical records regarding clinical data available, the time needed to retrieve data and the usefulness of the data. Of the 118 participants, 55% were dissatisfied/very dissatisfied with data availability and 61% with the time spent to access and update data related to the focused patient group. Despite this negative experience, 76% considered future e-Health solutions as pertinent/very pertinent. Subsequently, these findings were further explored with eight semi-structured interviews. The physicians confirmed the reported dissatisfactions and pointed out the lack of comprehensive data and system interoperability as serious problems, causing inefficient health services with an overlap of emergency visits and uncoordinated diagnostics and treatment. In addition, they discussed the importance of camera and audio monitoring to add significant value. Our results indicate considerable potential for e-Health solutions, but substantial improvements are crucial to achieving such future solutions.
... The ageing process has challenged the sustainability of the healthcare systems, including the Portuguese health system [1,5]. To address this, several approaches have been suggested, such as person-centered health systems and use of digital devices [2,3,[14][15][16][17][18] (Figure 1). ...
... As observed in other studies [14,15,17,36], the participants of the two focus groups highlighted several benefits of a digital rehabilitation service: comfort, closer physicianpatient interaction anywhere, the potential for patient's motivation and engagement with self-care. Additionally, the availability of the tutorial videos with balance exercises was considered as a positive factor, allowing patients to remember the exercises and motivating them to exercise, including outside the home. ...
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In this study, a design science research methodology was used aiming at designing, implementing and evaluating a digital health service to complement the provision of healthcare for elderly people with balance disorders and risk of falling. An explanatory sequential mixed methods study allowed to identify and explore the dissatisfaction with electronic medical records and the opportunity for using digital health solutions. The suggested recommendations helped to elaborate and develop “BALANCE”, a digital service implemented on the METHIS platform, which was recently validated for remote monitoring of chronic patients in primary healthcare. “BALANCE” provides clinical and interactive data, questionnaire pre and post-balance rehabilitation, tutorial videos with balance exercises and patient-recorded videos of the exercises. This digital service was demonstrated, including five elderly patients with clinical recommendations for balance rehabilitation at home. Finally, the authors conducted two focus groups with the participants and their caregivers as well as with physicians. The focus groups aimed at exploring their satisfaction level, needs of adjustment in the “BALANCE” service and strategies for applicability. The digital healthcare service evaluation revealed a significant potential for clinical applicability of this digital solution for elderly people with balance disorders and risk of falling.
... Related studies argue that mHealth innovations are well received by community health workers and are transforming their activities in the health systems (Agarwal et al. 2015;Bernasconi et al. 2019;Lapão et al. 2017). Community health workers are a core component of the health care sector in developing countries (Källander et al. 2013). ...
... The absence of such information threatens efforts towards achieving effective scale-up of mHealth pilot implementations (Mechael et al. 2010;Tomlinson et al. 2013). Particularly, empirical details about whether and how mHealth implementations affect and transform health workers in practice remains scarce in literature (Feroz et al. 2020;Lapão et al. 2017). Most research conducted in the domain lays much emphasis on adoption, acceptance, design, cost management and usage of the technology (Agarwal et al. 2015;Dehzad et al. 2014;Kenny et al. 2017;Ngoma 2014). ...
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The child mortality rate remains significantly high in many developing countries despite recent contemporary approaches to reducing child mortality rates across the globe. This is especially the case for armed-conflict settings such as Syria, Nigeria, and Niger where approximately 6 million children under the age of five died in 2015. Mhealth is considered a promising information and communication technologies in improving child health outcomes in such a peculiar setting with severe health care deficit. This study is concerned with the analysis of the outcomes of implementing mHealth for health workers' transformation in child health care. To illuminate such an investigation, the study employs the lens of the Cultural-Historical Activity Theory (CHAT). Concepts from CHAT are elaborated to give a deep underpinning of the implementation of ALAMANCH as an alternative model of activity in the child health care activity system. An action research case study approach was used to investigate this study. Observations and interviews were used as the drivers for data collection with semi-structured interviews as the main source of data collection. A total of 31 one-on-one semi-structured interviews were conducted with the health workers while a total of twelve sessions of observation were made in ten PHCs to observe pre and post ALAMANACH implementation processes. Our findings suggest that mHealth implementation has transformed the activities of health workers by creating new roles, division of labor, and new tools in the child health care service delivery system.
... One of the possible solutions being proposed to solve this problem is through the use of mobile health tools and applications. Mobile health (mHealth) technology refers to the use of mobile devices such as mobile phones and wearable devices in supporting medical and public health practices (Lapão et al., 2017). Nowadays, mHealth technology is being utilized for patient monitoring, digital therapeutics, and management of various medical conditions (Silva et al., 2015). ...
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Objective The study aims to develop a mHealth application for seizure management based on the human system integration (HSI) approach. Background Unmet healthcare needs among people with epilepsy continue to exist despite the advancement in healthcare technology. Current seizure management methods are found to be ineffective. Therefore, a more efficient strategy such as mHealth technology is necessary to aid seizure management. Method The needs identification phase involved identifying the user requirements by interviewing 10 stakeholders and conducting thematic analysis and needs interpretation technique. In the solution identification phase, the system requirements were derived using various human-centered design and systems engineering approaches and were evaluated through quality function deployment to determine design targets. For the design and evaluation phase, the design targets were reflected in the app through the iterative prototyping process, and the interface and functional design were evaluated by seven human factors and ergonomics experts and four stakeholders, respectively. Results Three primary needs and ten user requirements were derived from the needs identification phase. Ten out of fifteen system requirements were selected as design targets to be included in the final prototype. Results of the evaluation showed that the interface design of the proposed app showed superior usability compared to a competitor app and that the app functions were beneficial for the stakeholders. Conclusion The mHealth app designed through the HSI framework showed good potential in addressing the main issues in seizure management. Application The mHealth app design methodology based on the HSI approach can be applied to the design of small-scale systems in various domains.
... Estas falhas percebidas, entre outras, parecem refletir uma lacuna estrutural em colocar o cidadão no centro do Sistema, isto é, procurar responder de forma eficiente às suas necessidades, satisfação e expectativas enquanto indivíduo e membro da comunidade nos seus diversos papéis: ativo e saudável, doente, cuidador, e membro da família/comunidade (DGS, 2012). O aumento da utilização das novas tecnologias da comunicação e informação no sector da saúde veio ajudar a colmatar estes problemas, através da redução dos custos associados aos cuidados de saúde, da melhoria da eficiência dos cuidados prestados, da capacitação dos cidadãos no processo de tomada de decisão e, consequentemente, da promoção da sustentabilidade do Serviço Nacional de Saúde (Lapão & Dussault, 2017). ...
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... Research is scarce about the impact of these new forms of organisation on the provision of healthcare services. The alleged benefits of eHealth/mHealth for the improvement of healthcare services encompass a better availability, accessibility and acceptability (AAAQ) of the health workforce (Lapao and Dussault, 2017) 5 . The literature is not conclusive about the potential use of ICT in homecare for cost saving. ...
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... Conclusions: There are challenges to be overcomed to expand the use of Telehealth, and it is essential to strengthen policies, laws and regulations to guarantee sustainability and use. Analisar telessaúde em saúde pública pode contribuir para reconhecer seus benefícios potenciais, ampliar a utilização pelos profissionais de saúde e subsidiar a tomada de decisões políticas que orientem e regulamentem o uso 6,7 , e os estudos de avaliação são estratégicos para esse fim. ...
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De Nederlandse zorg presteert over het algemeen goed, maar er zijn in delen van de zorg grote knelpunten. Om kwaliteit en toegankelijkheid te kunnen borgen dient de zorg in financieel, personeel en in maatschappelijk opzicht houdbaar te zijn. Deze drie dimensies van houdbaarheid staan echter steeds meer onder druk door ontwikkelingen als vergrijzing, de opkomst van nieuwe zorgtechnologie en de toename van het aantal chronisch zieken. In het rapport Kiezen voor Houdbare Zorg. Mensen, middelen en maatschappelijk draagvlak (rapport nr. 104, 2021) komt de WRR tot de conclusie dat we – om de groei van de zorg te begrenzen - beter moeten gaan kiezen waar onze prioriteiten in de zorg liggen. Leidend zijn hierbij twee uitgangspunten. Waar kunnen we de meeste gezondheidswinst behalen? En in welke delen van de zorg moeten kwaliteit en toegankelijkheid versterkt worden?
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Background The rising prevalence of chronic diseases is pressing health systems to introduce reforms. Primary healthcare and multidisciplinary models have been suggested as approaches to deal with this challenge, with new roles for nurses and pharmacists being advocated. More recently, implementing healthcare based on information systems and technologies (e.g. eHealth) has been proposed as a way to improve health services. However, implementing online pharmaceutical services, including their adoption by pharmacists and patients, is still an open research question. In this paper we present ePharmacare, a new online pharmaceutical service implemented using Design Science Research. Methods The Design Science Research Methodology (DSRM) was chosen to implement this online service for chronic diseases management. In the paper, DSRM?s different activities are explained, from the definition of the problem to the evaluation of the artifact. During the design and development activities, surveys, observations, focus groups, and eye-tracking glasses were used to validate pharmacists? and patients? requirements. During the demonstration and evaluation activities the new service was used with real-world pharmacists and patients. ResultsThe results show the contribution of DSRM in the implementation of online services for pharmacies. We found that pharmacists spend only 50% of their time interacting with patients, uncovering a clear opportunity to implement online pharmaceutical care services. On the other hand, patients that regularly visit the same pharmacy recognize the value in patient follow-up demanding to use channels such as the Internet for their pharmacy interactions. Limitations were identified regarding the high workload of pharmacists, but particularly their lack of know-how and experience in dealing with information systems (IST) for the provision of pharmaceutical services. Conclusions This paper summarizes a research project in which an online pharmaceutical service was proposed, designed, developed, demonstrated and evaluated using DSRM. The main barriers for pharmacists? adoption of online pharmaceutical services provision were the lack of time, time management and information systems usage skills, as well as a precise role definition within pharmacies. These problems can be addressed with proper training and services reorganization, two proposals to be investigated in future works.
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Background Hospital-acquired infections are still amongst the major problems health systems are facing. Their occurrence can lead to higher morbidity and mortality rates, increased length of hospital stay, and higher costs for both hospital and patients. Performing hand hygiene is a simple and inexpensive prevention measure, but healthcare workers’ compliance with it is often far from ideal. To raise awareness regarding hand hygiene compliance, individual behaviour change and performance optimization, we aimed to develop a gamification solution that collects data and provides real-time feedback accurately in a fun and engaging way. MethodsA Design Science Research Methodology (DSRM) was used to conduct this work. DSRM is useful to study the link between research and professional practices by designing, implementing and evaluating artifacts that address a specific need. It follows a development cycle (or iteration) composed by six activities. Two work iterations were performed applying gamification components, each using a different indoor location technology. Preliminary experiments, simulations and field studies were performed in an Intensive Care Unit (ICU) of a Portuguese tertiary hospital. Nurses working on this ICU were in a focus group during the research, participating in several sessions across the implementation process. ResultsNurses enjoyed the concept and considered that it allows for a unique opportunity to receive feedback regarding their performance. Tests performed on the indoor location technology applied in the first iteration regarding distances estimation presented an unacceptable lack of accuracy. Using a proximity-based technique, it was possible to identify the sequence of positions, but beacons presented an unstable behaviour. In the second work iteration, a different indoor location technology was explored but it did not work properly, so there was no chance of testing the solution as a whole (gamification application included). Conclusions Combining automated monitoring systems with gamification seems to be an innovative and promising approach, based on the already achieved results. Involving nurses in the project since the beginning allowed to align the solution with their needs. Despite strong evolution through recent years, indoor location technologies are still not ready to be applied in the healthcare field with nursing wards.
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Background There is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health. MethodsMEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR). ResultsForty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation. Conclusion This systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary. Trial registrationPROSPERO, CRD42015017661
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Transnational mothers working in foreign countries face the challenges of providing ?intensive? mothering to their children from a distance, and risk being subject to the ?deviancy? discourse of mothering. This paper investigates the role of mobile phone usage, via voice, text messages, and social networking sites, in dealing with the tensions and ambivalence arising from transnational mothering as a dialectical process. We surveyed 42 Filipina and Indonesian foreign domestic workers (FDWs) in Singapore using a mixture of quantitative and qualitative methods. FDWs addressed tensions arising out of societal expectations of motherhood and their own anxieties about children?s well-being. The reluctant obsessive struggled to maintain a balance between an intensive nurturing style and a deviant mode of mothering that respected the growing independence of the children. The diverted professional had to balance the financial empowerment of being the primary breadwinner with the risk of surrogate motherhood for the employer?s children subsuming the care provided to her own. The remote-control parent shared mothering responsibilities with caregivers, usually relatives, who acted as a contradictory proxy presence for intensive mothering. The incomplete union of stressed marital parenting put further pressure on the romantic and sexual identities of migrant women. Transnational mothers utilized mobile phones actively as a tool to negotiate and redefine identities and relationships that created fissures in their sense of self. These included the management of third-party relationships, withholding of emotions or information, and engaging in counterintuitive phenomenon such as restricting, or actively dis-engaging from, mobile phone usage as a communication strategy. The paper calls for future research into the multiple, and interacting, social identities assumed and managed by transnational mothers, and the complex role played by mobile phones in the constant process of negotiation by agentic, self-relective and multifaceted women.
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Background: Health workforce planning is especially important in a setting of political, social, and economic uncertainty. Portuguese community pharmacists are experiencing such conditions as well as increasing patient empowerment, shortage of primary care physicians, and primary health care reforms. This study aims to design three future scenarios for Portuguese community pharmacists, recognizing the changing environment as an opportunity to develop the role that community pharmacists may play in the Portuguese health system. Methods: The community pharmacist scenario design followed a three-stage approach. The first stage comprised thinking of relevant questions to be addressed and definition of the scenarios horizon. The second stage comprised two face-to-face, scenario-building workshops, for which 10 experts from practice and academic settings were invited. Academic and professional experience was the main selection criteria. The first workshop was meant for context analysis and design of draft scenarios, while the second was aimed at scenario analysis and validation. The final scenarios were built merging workshops' information with data collected from scientific literature followed by team consensus. The final stage involved scenario development carried by the authors alone, developing the narratives behind each scenario. Results: Analysis allowed the identification of critical factors expected to have particular influence in 2020 for Portuguese community pharmacists, leading to two critical uncertainties: the "Legislative environment" and "Ability to innovate and develop services". Three final scenarios were built, namely "Pharmacy-Mall", "e-Pharmacist", and "Reorganize or Die". These scenarios provide possible trends for market needs, pharmacist workforce numbers, and expected qualifications to be developed by future professionals. Conclusions: In all scenarios it is clear that the future advance of Portuguese community pharmacists will depend on pharmaceutical services provision beyond medicine dispensing. This innovative professional role will require the acquisition or development of competencies in the fields of management, leadership, marketing, information technologies, teamwork abilities, and behavioural and communication skills. To accomplish a sustainable evolution, legislative changes and adequate financial incentives will be beneficial. The scenario development proves to be valuable as a strategic planning tool, not only for understanding future community pharmacist needs in a complex and uncertain environment, but also for other health care professionals.
The digital revolution is gradually transforming our society. What about the effects of digitalization and Internet of Things in healthcare? Among researchers two ideas are dominating, opposing each other. These arguments will be explored and analyzed. A mix-method approach combining literature review with the results from a focus group on eHealth impact on employment is used. Several experts from the WHO and from Health Professional Associations contributed for this analysis. Depending on the type of service it will entail reductions or more need of healthcare workers, yet whatever the scenario medical informatics will play an increasing role.
Technical Report
This report discusses the need for an integrated and cyclical approach to managing health technology in order to mitigate clinical and financial risks, and ensure acceptable value for money. The analysis considers how health systems and policy makers should adapt in terms of development, assessment and uptake of health technologies. The first chapter provides an examination of adoption and impact of medical technology in the past and how health systems are preparing for continuation of such trends in the future. Subsequent chapters examine the need to balance innovation, value, and access for pharmaceuticals and medical devices, respectively, followed by a consideration of their combined promise in the area of precision medicine. The final chapter examines how health systems can make better use of health data and digital technologies. The report focuses on opportunities linked to new and emerging technologies as well as current challenges faced by policy makers, and suggests a new governance framework to address these challenges.
Article
Background With rapidly expanding infrastructure in China, mobile technology has been deemed to have the potential to revolutionize health care delivery. There is particular promise for mobile health (mHealth) to positively influence health system reform and confront the new challenges of chronic diseases. Objective The aim of this study was to systematically review existing mHealth initiatives in China, characterize them, and examine the extent to which mHealth contributes toward the health system strengthening in China. Furthermore, we also aimed to identify gaps in mHealth development and evaluation. Methods We systematically reviewed the literature from English and Chinese electronic database and trial registries, including PubMed, EMBASE, Cochrane, China National Knowledge of Infrastructure (CNKI), and World Health Organization (WHO) International Clinical Trials Registry Platform. We used the English keywords of mHealth, eHealth, telemedicine, telehealth, mobile phone, cell phone, text messaging, and China, as well as their corresponding Chinese keywords. All articles using mobile technology for health care management were included in the study. Results A total of 1704 articles were found using the search terms, and eventually 72 were included. Overall, few high quality interventions were identified. Most interventions were found to be insufficient in scope, and their evaluation was of inadequate rigor to generate scalable solutions and provide reliable evidence of effectiveness. Most interventions focused on text messaging for consumer education and behavior change. There were a limited number of interventions that addressed health information management, health workforce issues, use of medicines and technologies, or leadership and governance from a health system perspective. Conclusions We provide four recommendations for future mHealth interventions in China that include the need for the development, evaluation and trials examining integrated mHealth interventions to guide the development of future mHealth interventions, target disadvantaged populations with mHealth interventions, and generate appropriate evidence for scalable and sustainable models of care.
Article
The modern smartphones contain different sensor technologies, so they can be used as stand-alone measurement instruments on a wide range of application domains. The paper deals with a survey of measurement applications based on smartphones. In the first part, the evolution of mobile phone technologies, including the sensors and mobile networks developments, is presented. Then, in order to highlight the sensors and the communication capabilities, the architectural overview of the hardware and software technologies, which are available on latest series of smartphones, is reported and discussed. A review of measurements applications using the smart sensors and the communication interfaces available on smartphones, it is also presented. A classification of smartphone applications, which looks the smartphone as a handheld measurement instrument, is presented. In the last part, the integration of augmented reality to the measurement applications and new type of measurement systems, having a smartphone as processing support, is presented.